Account:

Ordering Provider: Derek Shepherd, MD

Prepared: August 25, 2021 by MDR Care

Delivered: July 2021

Patient Evidence of Care

Patient Name:

Patient Date of Birth:

Patient MRN: 12345

Services Enrolled: RPM, CCM

Synced Devices: Blood Pressure

Summary

Task Summary

Tasks Status Type Scheduled Date

Care Plan Review COMPLETE on 07/28/2021 call 06/14/2021

Medication Reconciliation COMPLETE on 08/10/2021 call 08/10/2021

Notes and related tasks

Care Plan Review COMPLETE Created at: 05/31/2021 Updated at: 07/28/2021

Related Notes Date Description

Ashley, Petty, CMA 07/19/2021 1 minute Called patient for monthly health coaching call, patient

was unable to speak, call back later.

Cara, Steckert, CNA 07/28/2021 8 minutes Patient's Main discussion on Call: The patient is well and

has no concerns. We went over the Care Plan Review,

all questions answered.

Patient's Goal: Her goal is to lose weight. She is 10/10

ready to achieve this goal. Her motivation is to be a

healthier weight for her height. Vitals Being Tracked:

Weight, and Blood Pressure, and Heart Rate in RPM.

Upcoming Appointments: Orthopedic Doctor on Monday.

Cara, Steckert, CNA 07/28/2021 2 minutes Initiated Patient Health Assessment with patient during

monthly coaching call. Completed initial sections

including General Health, and Chronic Diseases. Patient

encouraged to complete remaining sections PHA through

patient portal prior to next month’s coaching call.

Medication Reconciliation COMPLETE Created at: 07/31/2021 Updated at: 08/10/2021

Clinical Care and Analysis

Sender Date Minutes Description

Marlene, Jimenez, MA 07/02/2021 2 RPM logged vitals reviewed. Current care plan appropriate for

patient at this time. No additional action needed. Will continue to

monitor patient vitals closely.

Tasks

All call, follow up, and escalation tasks Follow-ups

0

Escalations

0

Vital Tracking

Count of vitals provided by the patient either

online or over the phone Provided by patient

55

Messaging

Count of messages between a patient and

his/her care team From Patient to Care Team

0

From Care Team to Patient

9

Total Time Spent

Sum of minutes spent on care

of patient Total Minutes

48

Calls

1

Readiness for Change

Score assessed by Clinician as the patient's

readiness to make a change in their life (0-Not

ready, 5-unsure, 10-

Last 3 months

3

Current month

10

CCM Minutes

26

9 minutes of direct

messaging, 17 minutes

of clinical care and

analysis.

Engagement Score

Best score out of 5 that a patient can complete

either over the phone or online Current month

3

Out of Range

1

Alerts

Triggered when a patient logs a vital Standard

82

RPM Minutes

22

0 minutes of direct

messaging, 22 minutes

of clinical care and

analysis.

Grey Sloan Memorial Hospital

Doe, Jane

1950/01/01

Sender Date Minutes Description

Marlene, Jimenez, MA 07/08/2021 2 RPM logged vitals reviewed. Current care plan appropriate for

patient at this time. No additional action needed. Will continue to

monitor patient vitals closely.

Marlene, Jimenez, MA 07/13/2021 2 Vitals reviewed. Current care plan appropriate for patient at this

time. No additional action needed. Will continue to monitor patient

vitals closely.

Makenzie, Nimmick, CCP 07/15/2021 2 Vitals reviewed. Current care plan appropriate for patient at this

time. No additional action needed. Will continue to monitor patient

vitals closely.

Makenzie, Nimmick, CCP 07/16/2021 2 Vitals reviewed. Current care plan appropriate for patient at this

time. No additional action needed. Will continue to monitor patient

vitals closely.

Ashley, Petty, CMA 07/19/2021 4 Completed monthly pre-call review of chronic conditions,

associated goals, medication management review and

reconciliation. Reviewed demographics, problems and diagnoses,

allergies, prognosis and expected outcomes, planned interventions

and goals and care coordination.

Makenzie, Nimmick, CCP 07/23/2021 2 RPM logged vitals reviewed. Current care plan appropriate for

patient at this time. No additional action needed. Will continue to

monitor patient vitals closely.

Dailey, Avery, RN 07/27/2021 2 Vitals reviewed. Current care plan appropriate for patient at this

time. No additional action needed. Will continue to monitor patient

vitals closely.

Makenzie, Nimmick, CCP 07/28/2021 2 Vitals reviewed. Current care plan appropriate for patient at this

time. No additional action needed. Will continue to monitor patient

vitals closely.

RevUp, Nurse Group 07/30/2021 2 Patient data review with (and) triaging of critical data to delivery

RNs. Manage clinical escalations and follow-up.

Delivery, Management &

QA

07/30/2021 2 Care Team development, task management, work flow

management and skill development.

Delivery, Management &

QA

07/30/2021 2 Quality of patient care, risk analytics, adherence to protocol &

process, time spent per patient.

Marlene, Jimenez, MA 07/30/2021 2 Vitals reviewed. Current care plan appropriate for patient at this

time. No additional action needed. Will continue to monitor patient

vitals closely.

Patient Engagement Score - 3

7/1 - 7/31

Call Task Completed

Vitals logged by Clinician

Vitals logged by Patient

Session

Patient Sent Message

Patient Goal I want to lose weight

As selected by the patient during

coaching or app session Patient stated goal: lose weight

Commitment to track Weight, Activity, Meals, Medications

Staistics patient commits to

Readiness for Change 10

0-Not Ready, 5-unsure, 10-ready

4

* 3

* 2

* 1

2021-05-01 2021-06-01 2021-07-01

I+ Engagement Scores I

Patient Weight Over Past 92 Days

Patient Blood Pressure Over Past 31 Days

Patient Heart Rate Over Past 3 Months

146 - ---------------------r---------------------,----------------------r---------------------,---------------------- -

145 ~45.0 145,0

144

2021-05-15 2021-05-30 2021-06-14 2021-06-29 2021-07-14 2021-07-29

130

120

110

100

90

80

70

105

102

98

94

91

88

84

80

77

74

70

66

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I• Weight I

I I I I

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1 I I I

2021-07-05 2021-07-12 2021-07-19 2021-07-26

I• Systolic ...., Diastolic I

__ J _________________ ~-----------------L ________________ J _________________ L _________________ 1 _________________ J _____ _

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2021-04-30 2021-05-15 2021-05-30 2021-06-14 2021-06-29

I• Heart Rate I 2021-07-14 2021-07-29

Counts of all vitals

WEIGHT Last: Jul 28 2021, 4:24 PM 1

BLOOD PREASURE Last: Jul 31 2021, 11:58 54

PAIN TRACKING 0

MEALS LOGGED 0

STRESS 0

STEPS 0

BODY FAT 0

BLOOD SUGAR 0

SLEEP TRACKING 0

PHYSICAL ACTIVITIES 0

MOOD 0

MESSAGES SENT Last: Jul 27 2021, 12:38 PM 9

MEDICATION 0

HEART RATE Last: Jul 31 2021, 11:58 AM 54

BLOOD OXYGEN 0

BLOOD TEMPERATURE 0

Patient Direct Messaging Minutes & Topic

I• CCM: General Health I

Care Plan

PROVIDER

ACCOUNT

AGE

CCD DATE

DOB

NAME

MRN

PRIMARY LANGUAGE

CARE MANAGEMENT PROGRAM

Patient Problems

Care Management Focused Conditions:

Chronic conditions are expected to last at least 12 months, or life of the patient, and place the

patient at risk of functional decline or decompensation.

Diagnosis

Iron Deficiency

Aortic Regurgitation- Moderate

ASHD

Carotid Artery Stenosis

Colonic Polyps

Degenerative Joint Disease

Drop foot gait

Esophagitis

All known conditions:

Diagnosis

Essential (primary) hypertension

1950-01-01

Jane Doe

12345

07-30-2021

71

Grey Sloan Memorial Hospital

Derek Shepard, MD

English

RPM, CCM

Other specified peripheral vascular diseases

Diagnosis

Family History of Premature Ischemic Heart Disease

Hemangioma

Hiatal hernia

HTN, - Essen Benign

Hyperlipidemia, Mixed

Hypertensive Heart Disease

Hypothyroidism

Long Term Use Of High-Risk Medications

MGUS (monoclonal gammopathy of unknown significance)

Mitral Regurgitation

Multiple myeloma

Obesity

Osteoporosis

Patent Formen Ovale

Peripheral Vascular Disease

Thoracic Aortic Aneurysm

Tricuspid Regurgitation- Moderate

Allergies, Adverse Reactions, Alerts:

Description

Active Medications

Patient provided the following medication changes to the care team:

• Crestor take 1 tablet (5 mg) by oral route once daily for 90 days - created on 04/15/2021

• Vitamin D3 take 1 capsule by oral route daily - created on 04/15/2021

• levothyroxine take 1 tablet (50 mcg) by oral route once daily - created on 04/15/2021

• Calcium 250 MG Capsule Daily - created on 08/10/2021

NO KNOWN ALLERGIES

Reconciled date:

Medication Name Comments

250 MG Capsule, Daily Updated on 08/10/2021

iron 325 mg (65 mg iron) tablet, Takes every other

day Updated on 08/10/2021

Crestor, take 1 tablet (5 mg) by oral route once daily for

90 days Updated on 04/15/2021

levothyroxine, take 1 tablet (50 mcg) by oral route once

daily Updated on 04/15/2021

losartan, take 1 tablet (25 mg) by oral route once daily

for 90 days Updated on 04/15/2021

Vitamin D3, take 1 capsule by oral route daily Updated on 04/15/2021

08-10-2021

Patient provided the following medication changes to the care team:

• iron 325 mg (65 mg iron) tablet Takes every other day - created on 08/10/2021

Goals

Clinical goals:

Goal assigned Goal statement Expected time

frame

Monitor for signs of decreased energy, hair loss,

or feeling cold, and notify your physician if they

occur.

long

04/15/2021

Exercise (aerobic physical activity such as brisk

walking) regularly, as tolerated and

recommended by your doctor. Record your

activities into your RevUp dashboard/RevUp

Health Log.

long

04/15/2021

Monitor your blood pressure daily, and record

your readings into your RevUp dashboard/RevUp

Health Log.

long

04/15/2021

Take medications regularly as prescribed. Know

how to monitor the effectiveness of your meds,

and review with your provider.

long

04/15/2021

Goal assigned Goal statement Expected time

frame

04/15/2021

Monitor for symptoms and notify provider if they

worsen:

• Anxiety, irritability, or trouble sleeping

• Weakness (especially in the arms and thighs,

which can make it hard to lift heavy things or

climb stairs)

• Trembling

• Sweating a lot and having trouble dealing with

hot weather

• Fast or uneven heartbeats

• Feeling tired

• Weight loss even when you are eating

normally

long

04/15/2021

Adhere to a heart healthy diet (a diet that is rich

in vegetables, fruits, whole grains, and low-fat

foods). Decrease saturated fat intake. Consume

less than 200 mg of dietary cholesterol per day.

Record your meals into your RevUp

dashboard/RevUp Health Log.

long

04/15/2021

Be aware of the symptoms of thyroid storm and

seek medical attention right away if they occur:

• Heart rate above 140 beats per minute

• Blood pressure below 90/60 mm Hg

(Hypotension)

• Temperature of 104-106 degrees Fahrenheit

• Agitation, anxiety, confusion, stupor

• Severe nausea, vomiting, diarrhea, abdominal

pain, and jaundice (a yellowing of the skin and

eyes)

long

04/15/2021

Maintain a healthy weight or reduce your

weight, if recommended by your physician.

Record your weight into your RevUp

dashboard/RevUp Health Log.

long

Patient goals:

Goal statement I want to lose weight

Patient stated goal lose weight

Readiness for Change 10

08/25/2021

Date Updated:

Advance Directives

Unknown

Directive Yes/No Effective Date File Name

Social History

Unavailable

Status

Care Coordination

Preventative Care

07/28/2021Date

Have you had the following in the past year?

Tobacco Use

Flu Vaccine

Have you had the following in the past 5 years?

Pneumovax

TdAP (Tetanus Shot)

Lipid Screening

Mammogram

Osteoporosis Screening

(Bone density test)

Pap Smear

Have you had the following in the past years?

Colorectal cancer screening?

Weight Measurements

Blood Pressure Measurements

Patient Weight For July, 2021

146

145 -------------------------------------------------------•-------------------------------------------------------

144

2021-07-27 11:59 PM 2021-07-28 12:00 AM

I• Weight I

130

120

110

100

90

80

70

Patient Blood Pressure For July, 2021

'

------------------,-------------------

' '

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I I I I

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------------------,---------------------------~---------------------------~----------------------------1-----------------------

I I I I

--------------~---------------------------~---------------------------~----------------------------·-----------------------

1 I I I

2021-07-05 2021-07-12 2021-07-19 2021-07-26

I• Systolic

♦

Diastolic I

Patient Vital Signs Report

Patient:

PCP:

Account:

RevUp Patient Type: Hybrid

Prepared August 25, 2021 by MD Revolution

Synced Devices: Blood Pressure

Jane Doe

Derek Shepard, MD

Grey Sloan Memorial Hospital

No glucose measurements available.

Glucose Measurements

Meal Logs

No meal logs available.

No fat percentage measurements available.

Fat Percent Measurements

Steps Logged

No steps logs available.

No lab results available.

Lab Results

No exercises logs available.

Exercises Logged on RevUp

Patient Heart Rate Over Past 3 Months

105 --J-----------------1-----------------~----------------J-----------------L----------------~-----------------~------

1 I I I I I I

I I I I I I I

I I I I I ' '

102 --~-----------------t-----------------~----------------~-----------------~-------- ------~-----------------t------

98

94

91

88

84

80

77

74

70

66

1 I I I I ' '

I I I I I I I

--~-----------------t-----------------~----------------~-----------------~--------· ·------~-----------------t------

' '

- - - - - - - -.- - - - - - - - - - - - - - - - - I - - - - - - - - - - -

' '

--,-----------------T-----------------.-----------------,---------------

1 I I I

I I I I

2021-04-30 2021-05-15 2021-05-30 2021-06-14 2021-06-29

I• Heart Rate I 2021-07-14 2021-07-29